2013 Flashcards
A 55-year-old man with post-prostatectomy incontinence underwent placement of an artificial urinary sphincter with good results for three years. He now complains of recurrent incontinence. Examination of the device and cystoscopy suggests normal cycling and no cuff erosion. The next step is:
- deactivate device for a two month trial period
- alpha-blocker therapy
- antimuscarinics
- urodynamics
- surgical exploration for repair or replacement.
4
Urethral atrophy results from chronic compression of the corpus spongiosum by the cuff and is the leading cause of urinary incontinence in this setting. However, urodynamic evaluation may reveal involuntary detrusor contractions or decreased bladder compliance. Deactivation will not permit improved sphincter function. Surgical exploration is not indicated if the cause of the incontinence is unrelated to the device (e.g., detrusor overactivity or impaired compliance). Alpha-blockers would not be expected to have any effect on urinary incontinence in this case regardless of the underlying cause. Antimuscarinics would not treat causes of incontinence related to device malfunction. Treatment options for this patient would include downsizing the cuff movement to a more proximal or distal location or the addition of a second cuff placed in tandem.
The recommended method to prevent postoperative DVT in an otherwise healthy man undergoing TURP under spinal anesthesia is:
- subcutaneous low dose unfractionated heparin
- low molecular weight heparin
- aspirin
- early ambulation
- obtain preoperative lower extremity duplex studies.
4
The AUA Best Practices Policy on DVT prophylaxis stated that early ambulation is recommended for the vast majority of men undergoing TURP. Those men who are at increased risk for DVT (such as previous DVTs, malignancy, immobility, paresis, etc.) may benefit from pneumatic compressive stockings, subcutaneous low dose unfractionated heparin, or low molecular weight heparin (LMWH). However, the use of LMWH is contraindicated in a patient who receives spinal or epidural anesthesia as this is a FDA black box warning due to risk of spinal hematoma. Aspirin and other antiplatelet drugs, while highly effective at reducing vascular events associated with atherosclerotic disease, are not recommended for DVT prophylaxis in surgical patients. There is no indication for obtaining preoperative LE-duplex studies in an otherwise healthy male.
A 66-year-old woman has a polypoid mass at her urethral meatus. Office biopsy demonstrates a non-invasive high-grade squamous cell carcinoma. Radiologic staging reveals no evidence of regional or distant disease. The next step is:
- topical 5-FU cream
- laser fulguration
- circumferential excision including excision of anterior vaginal wall
- XRT with ilioinguinal lymphadenectomy
- anterior pelvic exenteration with pelvic lymphadenectomy.
3
In female urethral cancers, treatment recommendations are primarily dependent on tumor location and clinical stage. Local excision may be sufficient for the relatively uncommon small, superficial, distal urethral tumors, and can result in excellent functional results. For more proximal and advanced urethral tumors, a more aggressive approach is warranted. Small, exophytic, superficial tumors arising from the urethral meatus or anterior urethra (as in this case) may be surgically treated with circumferential excision of the distal urethra including a portion of the anterior vaginal wall. The distal third of the urethra may be excised while still maintaining urinary continence. Tumors in the distal urethra tend to be low stage, and cure rates of 70% to 90% have been achieved with local excision alone. 5-FU cream has been utilized in the treatment of carcinoma-in situ of the penis, but does not have a defined role in female urethral cancers. Although XRT has been effectively used for female urethral cancers, the addition of prophylactic lymphadenectomy in this choice makes it incorrect. Recommendations for performing groin dissection have been made only for patients who present with positive inguinal or pelvic lymphadenopathy without distant metastasis, or patients who develop adenopathy during surveillance. Anterior pelvic exenteration is employed for patients with proximal urethral cancers often as part of a multimodal approach including chemotherapy and XRT.
The nephrotoxic effect of cisplatin is due to:
- efferent arteriolar constriction
- afferent arteriolar constriction
- pre-existing plasma volume contraction
- a direct toxic effect on renal tubular cells
- renal tubular obstruction from drug precipitation.
4
Cisplatin nephrotoxicity is due to a direct toxic effect of the drug on renal tubular cells. Azotemia and dehydration are predisposing conditions which increase the risk of this complication. Cisplatin is not precipitated in the renal tubules nor does it affect glomerular hemodynamics.
A 45-year-old woman with prior pelvic radiation for cervical cancer develops severe hemorrhage from the right ureteral orifice during routine exchange of a chronic indwelling 6 Fr ureteral stent. Over the next six hours, she continues to bleed but remains stable. The next step is:
1 replace stent with 8 Fr stent
- right percutaneous nephrostomy
- ureteroscopy with fulguration
- angiography and placement of endovascular graft
- open exploration.
4
Most cases of ureteroarterial fistulas are reported in patients with a prior history of vascular disease, radiation therapy, or pelvic surgery, especially in the setting of indwelling ureteral stents. In fact, ureteroarterial fistulas are highly associated with indwelling stents. The routine urologic and radiologic evaluation of hematuria will not generally provide evidence of ureterovascular fistula. Even in suspected or proven cases, preoperative radiologic investigations including nonselective arteriography and pyelography are often nondiagnostic. This is especially true in patients with intermittent hematuria in whom there is no active bleeding at the time of the radiographic investigation, presumably because of thrombus over the site of the fistula. Selective or subselective arteriography of the iliac vessels may be more revealing in suspected cases, and provocative maneuvers such as stent removal or mechanical friction of the ureteral lumen by manipulation of the stent may be necessary to demonstrate the fistulous connection in patients without active bleeding undergoing angiography. These adjuvant maneuvers should be performed only with extreme caution in an appropriate setting where immediate angiographic or surgical intervention is possible. In a review, retrograde pyelography was diagnostic in only 6 of 10 patients in whom it was performed, and arteriography diagnosed a ureterovascular fistula in only 4 of 14 cases. Indirect evidence of a ureteroarterial fistula can be found on CT, but findings are usually nonspecific and suggestive only in retrospect after a confirmed diagnosis by other means. Nevertheless, in a stable patient with a suspected ureterovascular fistula, a full radiographic evaluation may be pursued, not only for diagnostic purposes but also to evaluate potential reconstructive options and in select cases to perform therapeutic angiographic embolization procedures. As these patients may present in extremis with hypotension and severe hemorrhage, surgical intervention must be considered early, especially since radiographic evaluation may be nondiagnostic. In this stable patient, an attempt at angiography and placement of an endovascular graft is warranted. Open exploration may be needed if hematuria persists. Replacement of the ureteral stent or percutaneous nephrostomy will not stop the hemorrhage. Ureteroscopy with fulguration will be unsuccessful with an arterial-ureteral fistula.
With a pneumoperitoneum of 15 mmHg, how does the HR, MAP, SVR, and GFR respond?
1
The pneumoperitoneum used in laparoscopy will have an effect on the cardiovascular, renal and respiratory systems. With pressures = 20 mmHg (most commonly used pressure for laparoscopy is 15 mmHg), heart rate, mean arterial pressures and systemic vascular resistance are all increased. Alterations in venous return and cardiac output are variable and are dependent on the hydration of the patient. In the hypovolemic or euvolemic state both venous return and cardiac output are decreased due to compression of the vena cava, however if the patient is hypervolemic, (fluid overloaded) the vena cave will resist the increase in the intraabdominal pressure and both venous return and cardiac output increased. The GFR is decreased due to compression of the renal vein and renal parenchyma by the elevated intraabdominal pressure.
A 22-year-old sexually active woman complains of vulvovaginal itching and flu-like symptoms. On physical exam, she is afebrile and the only finding is a fissure in the left labia majora with no vaginal discharge. Urinalysis is negative. The treatment that can prevent recurrence of her symptoms is:
- hydrocortisone cream
- diphenhydramine cream
- ceftriaxone IM
- imiquimod cream
- oral acyclovir.
5
This patient has genital herpes (herpes simplex virus, HSV), of which 85-90% are caused by HSV-2 and 10-15% are caused by HSV-1. Initial genital herpes infection is often associated with constitutional flu-like symptoms. While vesicular eruptions can be found on physical exam, women especially may present with atypical lesions such as abrasions, fissures or itching. Empiric treatment may be initiated. Diagnosis can be helped by serology tests for antibodies to HSV-2 and HSV-1. Antiviral creams are not helpful for genital herpes. Oral acyclovir has been shown to prevent recurrence of genital herpes and associated symptoms. Hydrocortisone cream is not recommended for the treatment of genital herpes, however, recent studies suggest that a combination of topical acyclovir and hydrocortisone cream may reduce the recurrence of herpes labialis. Ceftriaxone is an appropriate treatment for chancroid but not genital herpes. Topical imiquimod is not recommended for treatment of routine genital herpes but is being used to treat recalcitrant cases of acyclovir-resistant herpes in immunocompromised hosts.
Sodium reabsorption in the proximal tubule:
- results in a hypotonic tubular fluid
- occurs against a steep concentration gradient
- is accompanied by bicarbonate excretion
- occurs by an active transport mechanism
- is regulated by aldosterone.
4
About two-thirds of the glomerular ultrafiltrate is reabsorbed in the proximal tubule with little change in the osmolality or sodium concentration of the unreabsorbed fraction. In other words, fluid reabsorption in the proximal tubule is nearly isosmotic and is coupled to the active transport of sodium. Since chloride and bicarbonate are the primary anions in the extracellular fluid, most of the filtered sodium is reabsorbed with these anions. Because of the high water permeability of the proximal tubule, sodium transport occurs against a minimal concentration gradient. Aldosterone regulates sodium-potassium exchange in the collecting duct.
A 61-year-old man with a serum creatinine of 1.7 mg/dl has a 5 cm upper pole left renal mass. He undergoes left partial nephrectomy. After complete gross resection of the mass frozen section reveals lymphoma with diffuse infiltration of normal renal parenchyma by lymphoma at the margins. His cold ischemic time was 18 minutes. The next step is:
- no further operative intervention
- re-excision of tumor bed
- cryotherapy of margin
- biopsy of contralateral kidney
- radical nephrectomy.
1
The unexpected finding of renal lymphoma at the time of renal cortical tumor surgery is rare. Ninety percent of these cases are not primary renal lymphoma but rather systemic lymphoma with renal manifestation. Non-Hodgkin’s lymphomas are the most common subtype. Multifocal masses, bilaterality and regional lymphadenopathy are all more common in renal lymphoma than in renal cortical tumors. In this patient the presence of diffuse renal infiltration by lymphoma will make post-operative systemic therapy necessary. In the setting of compromised renal function every attempt should be made to spare the remaining nephron mass in preparation for systemic chemotherapy. Therefore further surgical intervention is not warranted and completion of the operation and subsequent postoperative discussion regarding systemic therapy is the most logical next step.
A healthy one-month-old girl has lower abdominal distention. An ultrasound demonstrates a cystic mass behind the bladder. Follow up MRI scan is shown. Physical exam reveals normal appearing genitalia with a single opening in the urethral position with no evidence of a vaginal opening. These findings are most consistent with:
- Mayer-Rokitansky syndrome
- androgen insensitivity syndrome
- transverse vaginal septum
- imperforate hymen
- CAH.
3
The MRI scan shows evidence of a distended upper vagina and presence of a uterus which is most consistent with either a transverse vaginal septum or distal vaginal agenesis. Transverse vaginal septa are believed to arise from a failure in fusion or canalization (or both) of the urogenital sinus and Müllerian ducts. Many of the patients present at puberty with primary amenorrhea and a distended upper vagina. A complete transverse vaginal septum may be located at various levels in the vagina, but there is a higher frequency in the middle and upper third of the vagina. Transperineal, transrectal, and abdominal ultrasonography and MRI scan may be beneficial in establishing the diagnosis and determining the location and thickness of a transverse vaginal septum. Vaginal atresia occurs when the urogenital sinus fails to contribute to formation of the lower (distal) portion of the vagina. Mayer-Rokitansky syndrome is characterized by either partial or complete absence of the vagina and coexisting uterine abnormalities, with the uterus either partially or completely absent. In Mayer-Rokitansky syndrome, the fallopian tubes and ovaries are present but may be either normal or hypoplastic. Two types exist, type I that involves only the Müllerian structures (vagina and uterus) and type II that will involve concurrent abnormalities of either the cardiac, renal or otologic systems. Androgen insensitivity syndrome is characterized by the absence of a uterus, salpinx, and upper 2/3 of the vagina, these structures regress under the active influence of MIF secreted from the testes. CAH infant will manifest an enlarged clitoris and genital ambiguity, with variable lengths of a urogenital sinus present dependent upon the degree of androgen secretion from the adrenal glands. An imperforate hymen should demonstrate a visible bulging membrane at the vaginal introitus.
A 34-year-old man amputates his penis during a psychotic episode. He is brought to the emergency department in stable condition with cold ischemia time of the amputated penis of six hours. Microvascular reconstruction or macroscopic replantation of the penile shaft provides an equivalent outcome for:
- penile skin preservation
- urethral stricture formation
- erectile function
- penile sensation
- infection.
3
Microvascular reconstruction involves reanastomosis of the dorsal arteries, dorsal vein, and nerves. Macroscopic replantation is the simple anastomosis of the corpora cavernosum and urethra. Erectile function after either microvascular reconstruction or macroscopic replantation of the penile shaft is roughly 50%. Penile skin loss, urethral stricture formation, and loss of penile sensation are all greater with macroscopic replantation as compared to microvascular reconstruction of the penile shaft. Infection of the penile shaft after either technique has not been studied to date.
A 71-year-old healthy, uncircumcised man has a 4 cm penile tumor and undergoes partial penectomy. Pathology reveals high grade squamous cell carcinoma invading the corpora cavernosum with negative surgical margins. After four weeks of antibiotic therapy, staging evaluation reveals bilateral bulky fixed, inguinal adenopathy and bilateral pelvic adenopathy. The next step is:
- pelvic lymph node biopsy
- sentinel inguinal lymph node biopsy
- XRT to inguinal nodes
- bilateral pelvic and inguinal lymph node dissection
- neoadjuvant cisplatin, ifosfamide, and paclitaxel.
5
This patient has a T2 (invasion into the corpus spongiosum or cavernosum) N3 (palpable fixed inguinal lymph nodes or nodal mas, either bilateral or unilateral) disease. In patients with unresectable primary tumors or bulky regional lymph node metastases, neoadjuvant treatment with a cisplatin-containing regimen is the most effective treatment modality and may allow curative resection. A phase 2 study using four courses of neoadjuvant paclitaxel, ifosfamide and cisplatin chemotherapy for TxN2-3 disease followed by bilateral inguinal lymph node dissections, and unilateral or bilateral pelvic lymph node dissections revealed excellent response with an objective response rate of 55% and complete pathologic response rate of 10%, toxicity was acceptable with no treatment-related deaths. This treatment is superior to single agent chemotherapy and has less toxicity than the previous multi-agent chemotherapeutic regimen of cisplatinum, bleomycin, and methotrexate. The optimal chemotherapy regimen however has yet to be determined. In this patient with bilateral bulky fixed nodes not responding to antibiotics, a needle biopsy of the lymph nodes could be considered for pathologic diagnosis. However, neither pelvic lymph node biopsy, sentinel inguinal lymph node biopsy, nor bilateral pelvic inguinal and inguinal lymph node dissection would be curative and would predispose the patient to non-healing surgical incision sites. Similarly, XRT to the inguinal nodes would not be curative for this extensive disease.
A 40-year-old man with spina bifida undergoes ileovesicostomy and bladder neck closure with omental flap interposition for severe incontinence. Three months later he develops recurrent incontinence from a vesicourethral fistula. The next step is:
- tube vesicostomy
- permanent nephrostomy tubes
- repeat bladder neck closure with omental interposition
- repeat bladder neck closure with rectus flap interposition
- ileal conduit.
4
Persistent vesicourethral fistula occurs frequently with bladder neck closure where vascularized tissue is not interposed between the bladder neck and urethra. Omentum is the most commonly used tissue for interposition but occasionally is not available or cannot be brought down to the level of the bladder neck closure. When this is not possible, or in high risk cases (radiated patients, persistent vesicourethral fistulae, etc.) a rectus abdominus pedicle flap can be used for interposition. Tube vesicostomy will not help this patient as he will continue to be incontinent and it has been a lengthy interval since his surgery. Permanent nephrostomy tubes are undesirable and the patient may well continue to be incontinent. An ileal conduit can be considered but would be significantly more extensive than repeating the bladder neck closure.
Radiation exposure from a single abdominal CT scan is:
- on average 50 times greater than that from an anterior-posterior abdominal x-ray
- is less harmful to the digestive organs compared to the brain
- results in less cancer risk in younger patients
- increased with automatic exposure-control option
- the result of non-ionizing radiation.
1
There are an estimated 60-70 million CT scans performed in the USA, perhaps with 33% being unnecessarily performed. CT scans generate ionizing radiation with resulting DNA damage that could result in the induction of cancer. The cancer risk of CT scans is higher in the pediatric population. Furthermore, the digestive organs are more sensitive to radiation injury than the brain. Newer CT scans have automatic exposure-control option which will decrease the radiation exposure. An abdominal x-ray results in a dose of 0.25 mSv to the stomach whereas a single CT scan of the abdomen can result in a radiation dose 50 times or greater to the stomach.
A 30-year-old man is diagnosed with stage 3 NSGCT. He undergoes radical orchiectomy and four cycles of BEP chemotherapy. His tumor markers have normalized. However, he has a 10 cm retroperitoneal mass and three 1 cm pulmonary masses (50%25 size reduction after chemotherapy). After his RPLND, the next step is:
- observation with serial imaging
- PET scan with resection of lung masses if positive
- resection of lung masses
- resection of lung masses if retroperitoneum has active tumor
- resection of lung masses if retroperitoneum has teratoma.
3
There is about 75% concordance between retroperitoneal pathology and pulmonary mass pathology, however, approximately 25% of cases will have discordant pathology (i.e., retroperitoneal fibrosis and active tumor or teratoma in the lung field). Therefore, post-chemotherapy thoracotomy yields important prognostic information and is curative in patients with resected teratoma and a subset of patents with viable tumor. PET scanning is a valuable decision making tool for retroperitoneal post-chemotherapy seminoma for residual masses greater than or equal to 3 cm. In this patient population, provided the PET scans are performed six weeks after the last chemotherapy cycle (decreased false positives), PET scans have a negative predictive value of 96% and a positive predictive value of 78% for active seminoma. This helps identify patients who merit additional treatment for post-chemotherapy seminoma retroperitoneal masses. PET scans usefulness, however, for the evaluation of supra-diaphragmatic, residual pulmonary nodules or mediastinal masses has not been extensively studied and recommendations for its use in this clinical situation have yet to be determined.
A 53-year-old diabetic man sustains a minor proximal crural perforation during primary implantation of a three-piece inflatable penile prosthesis via a penoscrotal approach. The best management is:
- abort the procedure
- secure exit tubing of the ipsilateral cylinder
- extend corporotomy for primary repair
- place a malleable implant
- direct closure via perineal approach.
2
A common intraoperative complication with penile prosthesis surgery is crural perforation. If this occurs with insertion of an inflatable device with attached tubing, placing a tunica albuginea closure suture on either side of the exit tubing to keep the cylinder in place has worked sufficiently without requiring a more extensive repair. A more significant perforation injury, including damage to the urethra, would require termination of the procedure. Placement of a malleable prosthesis is not advised as it cannot be secured and will be more likely to erode.
A 43-year-old man desires a biological child with his 38-year-old wife. Both testes are 5 cm in longitudinal axis and firm on physical examination. Two semen analyses show azoospermia with volumes of 2.1 and 2.3 ml. FSH is 2.8 IU/l. The next step is:
- adoption
- TRUS
- evaluation of the wife
- testicular sperm extraction with ICSI
- microsurgical scrotal ductal reconstruction.
3
The likelihood of obstructive azoospermia is 96% with testis longitudinal axis greater than 4.6 cm and FSH less than 7.6 IU/l. However, the most significant predictor of any form of reproductive intervention is maternal age, with female fecundity declining precipitously after age 37. The decision to perform microsurgical scrotal ductal reconstruction or to obtain sperm from the testis for IVF and intracytoplasmic sperm injection rests on evaluation of the female partner, especially after age 37. Transrectal ultrasound is not necessary if semen volumes are normal (> 1.5 ml) as ejaculatory ductal obstruction is unlikely.
A 66-year-old man undergoes a radical nephrectomy with adrenalectomy for an 8 cm upper pole RCC within the kidney. There is a focus of non-contiguous, metastatic RCC in the adrenal gland. No lymph nodes were removed. According to the 2010 TNM AJCC classification, pathologic stage is:
- T1bN0Mx
- T1bNxM1
- T2aNxM0
- T2aNxM1
- T4NxM0.
4
According to the 2010 TNM AJCC staging, renal cancers greater than 7 cm and less than or equal to 10 cm are now categorized as pT2a. Lesions greater than 10 cm are pT2b. Adrenal gland involvement depends on whether there is contiguous involvement (T4) or non-contiguous involvement (M1). The M1 designation is true even if the adrenal gland is on the ipsilateral side as the nephrectomy. When there are no pathologic lymph nodes available, the pathologic staging is designated as NX.
The finding most suggestive of renal artery stenosis on duplex ultrasonography is:
- decreased diastolic flow
- turbulent systolic flow
- increased peak systolic velocity
- renal aortic ratio < 3
- resistive index < 0.8.
3
Duplex ultrasound of the renal arteries is a useful noninvasive anatomic study for the diagnosis of renal artery stenosis (RAS). Although an altered flow pattern distal to the stenosis, including decreased diastolic flow and a turbulent systolic jet, can be suggestive of RAS, the most important single indicator is a peak systolic velocity (PSV) > 180 cm/sec. The renal aortic ratio (RAR) is the ratio of renal PSV to the aortic PSV. A RAR > 3.5 indicates > 60% stenosis. The renal resistive index does not directly assess renal artery flow.
A 28-year-old man with Kallmann syndrome is treated with exogenous testosterone. He desires a biological child. Semen analysis reveals a volume of 2.2 ml and azoospermia. The next step is:
- post-ejaculate urinalysis
- assay testosterone, LH, and FSH
- administer GnRH
- administer hCG and recombinant FSH
- testicular sperm extraction for IVF.
4
Kallmann syndrome, anosmia or hyposmia associated with hypogonadotropic hypogonadism is commonly diagnosed due to a delayed onset of puberty. Most patients are treated with exogenous testosterone at the time of their diagnosis for virilization. Testosterone is easy and cost effective to administer compared to daily injections of alternative hormones. Azoospermia in these patients results from the combination of inadequate levels of intratesticular testosterone, and the patient’s natural absence of stimulatory pituitary hormones. When the patient desires to father children, spermatogenesis can be brought about by discontinuing parenteral testosterone and beginning daily IM or SQ injections of hCG and recombinant FSH. If the response is insufficient, GnRH administration may be considered but is expensive and requires I.V. administration. In patients with low ejaculate volume (< 1.5 ml), a post-ejaculate urine is useful to diagnose retrograde ejaculation, this patient’s ejaculate volume is normal. Assay of testosterone, LH and FSH is not needed in this patient in whom a diagnosis of Kallmann syndrome has already been made. It would be inappropriate to proceed with testicular sperm extraction without first giving the hormonal treatment necessary to stimulate spermatogenesis.
A healthy 66-year-old woman has a loopogram as shown seven years following cystectomy and ileal conduit for bladder cancer. CT scan demonstrates bilateral hydronephrosis and no evidence of recurrent disease. Chest x-ray and urine cytology are normal. Serum creatinine is 1.8 mg/dl. A renogram is also shown. The next step is:
- looposcopy
- bilateral percutaneous nephrostomy
- stomal revision
- revision of left ureteroileal anastomosis
- left nephroureterectomy.
5
This patient has developed upper tract deterioration following cystectomy and ileal conduit diversion. This has been reported in some series to occur in over 50% of patients with long-term followup. The renogram in this instance demonstrates no obstruction to the right renal unit with hydronephrosis likely the result of chronic reflux. The renogram also demonstrates no significant function of the left renal unit. Because there is no reflux into the left system it cannot be monitored as to the possible development of upper tract urothelial carcinoma. In this setting, nephroureterectomy is recommended. Looposcopy will not add to the evaluation as it will not provide access to the left system. Bilateral percutaneous nephrostomy is not indicated because there is no evidence of obstruction of the right side. Similarly, there is no evidence of stomal stenosis. Revision of left ureteroileal anastomosis should not be undertaken for a non-functioning kidney. Another option would be left nephrostomy tube placement, antegrade studies, and selective cytology to further risk stratify the patient prior to making a final decision.
A 64-year-old man had a TURP six months ago and has an AUA Symptom Score of 5. He has persistent gross hematuria requiring cystoscopy and clot evacuation. Friable prostatic tissue was noted during cystoscopy. He does not wish to undergo further surgical treatment. The next step is:
- tamsulosin
- finasteride
- tamsulosin and finasteride
- bicalutamide
- antibiotics for one month.
2
Finasteride is an effective option for the management of gross hematuria after TURP for BPH. None of the other listed treatments (e.g., tamsulosin and bicalutamide) have efficacy or have been evaluated in this setting. It is known that one of the early effects of finasteride is the intraprostatic suppression of vascular endothelial growth factor. Clinically, finasteride has been shown to effectively treat post-prostatectomy hematuria, especially in the presence of friable prostate tissue. If hematuria does not resolve with this therapy then evaluation of the upper urinary tract should be considered to rule it out as the source of bleeding. Prolonged antibiotics would only be indicated in the setting of UTI suspected to be of prostatic origin.
A 56-year-old man has low libido and a normal physical exam. Morning serum testosterone is 365 ng/dl and prolactin is 48 ng/ml (normal < 20 ng/ml). The next step is:
- repeat prolactin assay
- serum LH assay
- pituitary MRI scan
- testosterone replacement
- bromocriptine.
1
Elevated serum prolactin from a pituitary tumor that causes clinical symptoms such as low libido, infertility and gynecomastia is usually accompanied by a low serum testosterone. A mildly elevated prolactin, especially accompanying a serum testosterone in the normal range, is rarely clinically significant. Because prolactin has high interassay variability, an elevated prolactin should first be verified by repeat testing. With a normal testosterone, LH assay is unhelpful and exogenous testosterone is not indicated. Likewise, a man with mildly elevated prolactin and normal testosterone is unlikely to benefit from bromocriptine, and MRI is unlikely to reveal a clinically significant anatomic pituitary lesion. The most common cause of low libido in a man with a normal physical exam and adequate testosterone is psychological.
The neurovascular bundles on the prostate travel between the following two layers of fascia:
- levator and prostatic
- Denonvilliers’ and levator
- Denonvilliers’ and prostatic
- lateral pelvic and prostatic
- lateral pelvic and levator.
1
The prostate is covered with three distinct and separate fascial layers: Denonvilliers’ fascia, the prostatic fascia, and the levator fascia.
Denonvilliers’ fascia is a filmy, delicate layer of connective tissue located between the anterior walls of the rectum and prostate.
The neurovascular bundle on the prostate contain the cavernosal nerves and are located between the layers of the levator fascia and prostatic fascia (in the lateral pelvic fascia)
A 71-year-old woman has difficulty voiding two hours following injection of a transurethral bulking agent. Residual urine volume is 400 ml. The next step is:
- observation
- alpha-blockers
- CIC
- indwelling urethral catheter
- suprapubic cystostomy.
3
Although the majority of patients do not have difficulties voiding following injection of a bulking agent, when retention does occur, it should be treated with CIC using a small (10- 14 Fr) catheter. Larger catheters, indwelling catheters. or large urethral sounds will push the mucosal blebs apart or cause molding of the bulking agent around the catheter. Suprapubic cystotomy can be used if long term catheterization is needed, although this is very rare.
A 27-year-old woman in the seventh week of pregnancy has right flank pain. Ultrasonography demonstrates a 5 mm calculus at the right UPJ. Urine culture is negative. The next step is:
- hydration and analgesics
- stone protocol CT scan
- ureteral stent
- percutaneous nephrostomy
- SWL.
1
Between 66% and 85% of women with ureteral colic will spontaneously pass their calculi with hydration and analgesic therapy. If the calculus fails to pass with conservative therapy, a ureteral stent should be placed cystoscopically with sonography or minimal radiographic imaging, as the first trimester presents the period of greatest risk of teratogenicity and spontaneous abortion. Ureteroscopy is an acceptable alternative. Fluoroscopy should be avoided. Pregnancy is an absolute contraindication for the use of SWL.
A 25-year-old man has a solid testes mass. His tumor markers are negative. He has an 8 cm retroperitoneal mass and multiple 1-2 cm. pulmonary metastases. His radical orchiectomy reveals pure seminoma. After chemotherapy his retroperitoneal mass is 2.8 cm and his pulmonary masses have resolved. PET/CT reveals no enhancement of his retroperitoneal mass. The next step is:
- observation
- percutaneous biopsy of retroperitoneal mass
- resection of retroperitoneal mass
- bilateral RPLND
- salvage chemotherapy.
1
PET imaging is useful to assess post-chemotherapy residual masses after treatment of seminoma. Lesions that are less than 3 cm or non-enhancing can be safely observed as over 90% of seminoma postchemotherapy masses are fibrosis. Percutaneous biopsy is not reliable since the masses can be heterogeneous. Resection of non-enhancing masses is not necessary and resection of seminoma post-chemotherapy masses can be technically difficult or impossible. Resection of the mass and bilateral RPLND would be appropriate for NSGCT post-chemo masses but are not necessary in the post-chemo seminoma setting because of the low risk of cancer or teratoma in the remainder of the retroperitoneum. Salvage chemotherapy is not necessary and is highly toxic.
Normal bladder compliance during physiologic filling is primarily due to: autonomic nerve activity
- circulating hormones
- cholinergic receptor activity
- local secretion of nitric oxide
- bladder wall viscoelasticity.
5
The main determinants of compliance are the elastic and viscoelastic properties of the bladder. When these are destroyed as in fibrosis of the bladder, poor compliance results. Neurogenic influences may be operative in late stages of filling. Bladder smooth muscle maintains a steady level of contractility and tone that is dependent on the activity in the autonomic nerves, circulating hormones, local metabolites, locally secreted agents such as nitric oxide, and temperature.
A 32-year-old man has azoospermia. Y chromosomal microdeletion assay reveals azoospermia factor b (AZFb) and azoospermia factor c (AZFc) deletions. The next step is:
- adoption
- clomiphene citrate
- recombinant FSH
- testis biopsy
- microsurgical testicular sperm extraction.
1
The long arm of the Y chromosome harbors genes intrinsic to spermatogenesis, including the azoospermia factor (AZF). While males with AZFc deletions may or may not have sperm in the seminiferous epithelium, an AZFa and/or AZFb deletion in combination with an AZFc deletion uniformly results in a Sertoli cell only phenotype. Biopsy is unnecessary, and microsurgical testicular sperm extraction will not yield sperm. Endocrine therapy with clomiphene citrate to stimulate Leydig cell production of testosterone, or with recombinant follicle stimulating hormone to stimulate Sertoli cell function, will not yield sperm as no germ cells are present.
A 71-year-old man previously treated for CIS of the bladder has a positive fluorescence in-situ hybridization (FISH) urine test. Cytology, CT urogram, and cystoscopy are normal. The next step is:
- observation
- repeat FISH test
- random bladder biopsies
- bilateral upper tract cytology
- bilateral ureteroscopy.
3
The urinary FISH test identifies intranuclear chromosomal abnormalities that have been associated with bladder cancer. Specifically it detects aneuploidy for chromosome 3,7 and 17 and homozygous loss of chromosome 9p21. This test is currently FDA approved for the evaluation of microscopic hematuria and bladder cancer. In 2007 Yoder and colleagues reported that 35/56 (62.5%) patients with prior urothelial carcinoma who had a normal evaluation by cystoscopy and a positive FISH subsequently were detected to have recurrent disease. The appropriate workup of this patient population remains highly variable, however random bladder biopsies are considered the standard of care for patients with a positive urine cytology and negative cystoscopy and should be regarded as a minimum evaluation in this high risk patient. The yield of upper tract endoscopy and cytology in the setting of a normal CT urogram is low and should be discouraged as an initial diagnostic maneuver. Because the patient has a history of bladder cancer, the most likely site of recurrence is in the bladder. Repeat FISH will not add anything to the evaluation, whether positive or negative.
A 58-year-old man has frequency and bothersome nocturia with an AUA Symptom Score of 16. History and physical exam are normal, Urinalysis is negative. The next step is:
- frequency-volume chart
- serum creatinine
- uroflowmetry
- cystoscopy
- pressure-flow study.
1
According to the recently updated guidelines on management of BPH by the AUA Practice Guideline Committee, recommended components of the diagnostic algorithm for routine evaluation include history, assessment of LUTS with an AUA Symptom Score, physical examination including DRE and UA. A frequency-volume chart should be obtained if nocturia is a predominant symptom. Urodynamics, cystoscopy and serum creatinine are not required as part of the initial evaluation.
A 52-year-old man requires six units of packed red blood cells over a 48-hour period five days after a percutaneous nephrolithotomy. He remains hypotensive at 85/50 mmHg. Imaging study is shown. The next step is:
- emergent exploration and repair of kidney
- selective arterial embolization
- bedrest, blood transfusion, and close monitoring
- insertion of a large-bore percutaneous tamponade catheter in nephrostomy tract
- insertion of an indwelling ureteral stent and urethral catheter decompression.
2
Delayed bleeding after percutaneous procedures is almost always secondary to pseudoaneurysms or arteriovenous fistulas. Both can present with delayed and intermittent bleeding. Arteriovenous fistula bleeding is more likely to be continuous compared with pseudoaneurysms. Management is renal angiography during active bleeding (with the aid of an arterial vasodilator such as papaverine if necessary) and highly selective angiographic embolization. Continued conservative therapy would be incorrect in the face of hemodynamic instability after appropriate resuscitative efforts. A tamponade catheter may be used as a temporizing measure if the nephrostomy tract is still present. The image presented demonstrates absence of a nephrostomy tube. An indwelling ureteral stent will not address the ongoing hemorrhage. Emergent exploration may lead to need for nephrectomy and a conservative approach is more appropriate.
A 40-year-old newly-diagnosed HIV positive man has a 2.0 cm. painless red nodule on his glans penis. A biopsy confirms Kaposi’s sarcoma. The next step is:
- initiate highly active antiretroviral therapy (HAART)
- systemic chemotherapy
- laser ablation
- excise the lesion
- partial penectomy.
1
The first step in treatment of Kaposi’s sarcoma in patients with HIV is to initiate HAART or to optimize the HAART regimen, which generally results in remission of Kaposi’s sarcoma. Local treatment can include laser therapy, cryotherapy, surgical excision, application of topical retinoids. Disseminated or visceral Kaposi’s sarcoma is treated with combination chemotherapy. The gold standard combination therapy of doxorubicin, bleomycin and vincristine has been replaced in recent years with liposomal anthracyclines, such as doxorubicin. Kaposi’s sarcoma is also often seen in immunosuppressed patients, such as renal transplant patients, and in this setting the treatment is a reduction of the immunosuppressive regimen. In the current era of immunosuppression, the frequency of this is diminished.
A 78-year-old malnourished woman with a history of prior pelvic radiation for cervical cancer undergoes a radical cystectomy and ileal loop diversion with bilateral ureteral stents for urothelial cancer. At the time of surgery, the bowel shows signs of radiation changes. Four days post-operatively, her urine output decreases with a marked increase in output from her abdominal drain. The next step is:
- parenteral hyperalimentation
- placement of a catheter into the ileal stoma
- bilateral percutaneous nephrostomy tube placement
- revision of the ureteroileal anastomoses
- excision of the ileal loop and replacement with a transverse colon conduit.
2
Leakage and fistula from urinary diversion occur in 2 to 9% of patients. However, 20 to 60% of these fistulae close spontaneously. Conservative management can be safely attempted assuming the patient is not septic and that adequate drainage is maintained. Leakage could be from the ureteral ileal anastomosis or from the butt end of the conduit. Bilateral ureteral stents are already in place, which should address any concerns about a ureteral ileal anastomotic leak. Therefore, the best initial therapeutic maneuver in this patient is placement of a catheter into the ileal loop to facilitate drainage. While hyperalimentation is important in malnourished patients and should also be initiated, this would not address the immediate issue of the leak. If the stomal catheter failed to decrease the fistulous output, bilateral percutaneous nephrostomy tubes could be placed to divert the urinary stream. If this failed, surgical intervention would be required to address the problem.
During ureteroscopic lithotripsy of an impacted 8 mm calcium oxalate stone in the proximal ureter, the ureter is cleared, but a 3 mm fragment is detected on fluoroscopy 1 cm lateral to the ureter. The next step is:
- observation
- ureteral stent
- basket extraction
- percutaneous nephrostomy
- retroperinoscopy.
2
A small stone fragment pushed through the wall of the ureter, if completely outside the wall and uninfected, is rarely a clinical problem and no intervention, such as retroperitoneoscopy or basket extraction, needs to be directed towards it. The ureteral perforation through which this fragment passed is managed by ureteral stenting; observation without a stent would lead to extravasation and a higher risk of stricture. Percutaneous nephrostomy and drain placement are not necessary if a stent can be inserted.
A man with castrate-resistant prostate cancer and bone metastases is on leuprolide acetate injections and intravenous zoledronic acid injections. He is asymptomatic. Zoledronic acid injections must be stopped if the patient develops:
- fever
- fatigue
- a tooth abscess
- a pathologic fracture
- severe osteoporosis.
3
Zoledronic acid and other bisphosphonates have become an important part of the management of patients with prostate cancer bone metastasis. These compounds reduce bone resorption by inhibiting osteoclastic activity and proliferation. In patients with progressive hormone refractory bone metastatic prostate cancer, zoledronic acid has been shown to reduce the incidence of skeletal events in a randomized prospective trial. Adverse events include fatigue, myalgias, fever, anemia and elevations in serum creatinine. Osteonecrosis of the mandibular bone is a severe complication of bisphosphonates usually associated with patients undergoing dental work or who have poor dentition or chronic dental disease. The bisphosphonates should be immediately discontinued in the setting of osteonecrosis or expected invasive dental procedures.
In the management of advanced urologic malignancies, stimulation of T cells by dendritic cells:
- is restricted to the Class I MHC (major histocompatibility complex)
- causes T cell differentiation into plasma cells
- is suppressed by TNF (tumor necrosis factor)
- is augmented by blockade of the T cell receptor
- produces interleukins.
5
An integral part of the immune response involves the activation of T cells by dendritic or antigen presenting cells. This interaction occurs via the T cell receptor in the context of MHC (major histocompatibility complex) class II molecules. B cells, unlike T cells, can be directly stimulated by antigen, which then allows B cell differentiation into antibody producing plasma cells. TNF (tumor necrosis factor) and other cytokines are produced by activated T cells and augment the cellular and humoral immune response. An FDA-approved autologous dendritic cell therapy, sipuleucel-T, is currently available for the treatment of advanced prostate cancer.
A 38-year-old woman has intermittent right flank pain. CT scan shows delayed filling of a right upper pole anterior calyceal diverticulum containing an 8 mm stone. The best treatment is:
- observation
- SWL
- ureteroscopy, incision of the diverticular neck and laser lithotripsy
- percutaneous nephrostolithotomy and dilation of the infundibular neck
- laparoscopic ablation of calyceal diverticulum and stone removal.
3
Observation is unacceptable in this symptomatic patient with a diverticular stone. Although SWL may be used successfully to treat a subset of patients with stones in calyceal diverticula that have a broad infundibular neck, the overall stone free rates with SWL are unacceptably low. Percutaneous nephrostolithotomy is not only associated with the highest stone-free rate, but also the procedure results in resolution of the diverticulum. However, anteriorly-located diverticula necessitate percutaneous access through the renal parenchyma with a high risk of bleeding complications. The ureteroscopic approach is ideal for upper pole calyceal diverticula with < 2 cm stones. Laparoscopic ablation would be indicated for an anterior calyceal diverticulum > 2 cm.
In a patient with muscle invasive urothelial carcinoma, the pathologic characteristic that predicts a poor response to neoadjuvant chemotherapy is:
- squamous differentiation
- lymphovascular invasion
- micropapillary variant
- p53 mutation
- small cell component.
3
Patients with histologic variants of urothelial carcinoma including squamous differentiation and small cell component actually appear to respond better to neoadjuvant chemotherapy. Similarly patients with a p53 mutation and lymphovascular invasion are considered higher risk patients with urothelial cancer and are recommended to have neoadjuvant chemotherapy. Micropapillary variant of urothelial carcinoma is the one variant that does not appear to respond to chemotherapy and requires immediate cystectomy.
A 62-year-old woman with multiple sclerosis has persistent urinary urgency and frequency. Pressure flow urodynamics reveal detrusor overactivity during bladder filling that reproduces her symptoms as well as increased pelvic floor EMG activity during voiding. An MRI scan will most likely reveal evidence of demyelination:
- of the cerebral cortex
- of the cerebellum
- between the pons and sacral spinal cord
- between the conus medullaris and the cauda equina
- between the sacral spinal cord and the bladder.
3
Multiple sclerosis may involve the central and/or peripheral nervous systems. Depending on the location, level and extent of demyelination, a variety of urodynamic patterns may result. Pelvic floor EMG activity in this individual is increased during voiding which suggests striated sphincter dyssynergia, a urodynamic finding that exists only with neurological lesions between the pons and the sacral spinal cord. Lesions at or distal to the sacral spinal cord would likely result in detrusor areflexia and lesions above the pons result in detrusor overactivity with synergistic activity of the proximal and distal sphincter mechanisms.
A 28-year-old woman awaiting a liver transplant because of primary biliary cirrhosis is symptomatic from a 9 mm proximal ureteral stone. Management should be:
- observation and hydration
- ureteral stent
- SWL
- stent placement and SWL
- ureteroscopic laser lithotripsy.
5
A 9 mm stone in the proximal ureter has little chance of spontaneous passage; as such, observation is futile. Although SWL and ureteroscopy are both acceptable treatment options for management of a proximal ureteral stone, uncorrected bleeding diathesis frequently found in patients with liver dysfunction is a contraindication to SWL. Although it is optimal to correct bleeding diatheses prior to surgical intervention for stones, full correction of coagulation parameters often requires administration of multiple blood products and lengthy hospital stays. Ureteroscopy and Holmium:YAG laser lithotripsy has been shown to be safe and effective in patients with uncorrected bleeding disorders.
A six-year-old girl undergoes bilateral ureteral reimplantation. On the first post-operative day, she has severe bladder spasms refractory to parenteral opioids and oral antimuscarinic agents. Her urine is clear, and the creatinine is 0.4 mg/dl. The next step is:
- oral alpha blocker
- oral benzodiazepine
- rectal acetaminophen
- IV ketorolac
- caudal block.
4 For post-operative bladder spasms refractory to the conventional pain management using opioids and antimuscarinics, intravenous ketorolac (NSAID) administered at 0.25 to 0.5 mg/kg every six hours is effective in reducing bladder spasms following bladder surgery. However, significant adverse effects have been reported including renal failure, prolonged bleeding and hypersensitivity reactions. It should be avoided in patients with renal insufficiency, NSAID sensitivity, persistent post-operative bleeding, and dehydration. Other treatments such as alpha blocker, benzodiazepine, rectal acetaminophen and caudal block do not provide any additional benefit.
A 26-year-old woman has a 2 cm, circumferentially calcified saccular aneurysm on renal arteriography. Her blood pressure is 126/82 mm Hg and her creatinine is 1.1 mg/dl. She is newly married and considering pregnancy. The next step is:
- observation
- serial imaging
- lisinopril
- endovascular stent
- surgical repair.
5
Pregnancy is a risk factor for renal artery aneurysm rupture, regardless of size or calcification, therefore observation and serial imaging are not recommended. If this was not a woman of child-bearing age, the aneurysm could be followed, as it is not large and completely calcified. Lisinopril will not reduce the likelihood of rupture or ischemic damage. An endovascular stent is not recommended for someone in this age group, due to the risk of lifelong anticoagulation therapy. She should be counseled to undergo surgical treatment of her aneurysm prior to becoming pregnant.
A 35-year-old man with uric acid calculi has a nighttime urinary pH of 5.5, despite potassium citrate 40 mEq TID. The next step is adding:
- allopurinol
- acetazolamide
- ascorbic acid
- sodium citrate
- hydrochlorothiazide.
2
Acetazolamide is effective in increasing the urinary pH in patients with uric acid and cystine stone formation who are already taking potassium citrate. However, 50% of patients may discontinue the medication due to adverse effects. Acetazolamide, a carbonic anhydrase inhibitor, leads to an increase in urinary bicarbonate and increased H+ reabsorption. It has been shown to increase overnight urine pH when given at bedtime. Allopurinol is effective for uric acid stones but does not increase pH, and might be considered but only if urinary uric acid levels were high. Sodium citrate has been shown to be less effective than potassium citrate therapy. Hydrochlorothiazide may increase urine uric acid.
A five-year-old boy has developed frequent daytime urination, voiding at least every 30 minutes. He has no nocturia. Since toilet training at age two, he has been continent day and night. His urinalysis is normal. The most appropriate management is:
- reassurance
- VCUG
- antimuscarinics
- glucose tolerance test
- cystoscopy.
1
Excessive urinary frequency in children is occasionally seen. The diagnosis is made by noting that the patient is continent of urine day and night and the UA is normal. The key to the diagnosis is that the frequency does not persist at night. In this child, his urinary frequency falls under the category of a nervous habit, and may be associated with emotional stress. Urinary frequency generally goes away over time averaging three to six months. It can return in some patients but eventually resolves. Antimuscarinics seldom help these patients whose bladders are normal. Invasive testing such as VCUG and cystoscopy are not indicated since the findings are almost always normal. In the presence of a normal UA, glucose tolerance testing is not indicated.
A 38-year-old woman develops monthly cyclical episodes of hematuria and menouria one year following Caesarean section. She does not desire more children. CT urogram demonstrates contrast in the bladder and uterine cavity; there is no hydronephrosis. The best treatment is:
- cystoscopy, fulguration and catheter drainage
- LH-RH agonist
- transvaginal repair with Martius flap
- transvaginal repair with omental flap
- transabdominal repair with hysterectomy.
5
Vesicouterine fistula (also known as, Youssef syndrome) is found to be the etiology for 2-4% of all GU fistula. A vesicouterine fistula is a rare complication that classically develops following a Cesarean section. The mechanism of the injury occurs as a consequence of incorporating the bladder wall with the sutures used to close the Cesarean section site, hence, it is frequently a delayed complication noted only as the sutures dissolve. It is also occasionally seen to arise following a dilation and curettage (D and C) procedure or as a consequence of a vaginal delivery following a prior Cesarean section. Due to the sphincteric like activity of the uterine cervix, these patients may not present with urinary incontinence. Indeed, 60% of the patients will present with intermittent or cyclical gross hematuria (menouria; menstrual tissue passed through the urine when voiding) as their only symptom, 20% with chronic urinary incontinence (incompetent uterine sphincter), and 20% with the classic Youssef triad: menouria, amenorrhea (all menstrual tissue passed into the urine) and chronic urinary incontinence. Since radiographic and endoscopic studies may frequently be inconclusive, the diagnoses of this complication requires a high degree of clinical suspicion. Tests used will consist of cystoscopy in an attempt to visualize the fistula tract, ultrasonography, CT cystogram, MRI scan, or hysterosalpingogram, the latter of which is presumably the most certain diagnostic technique available. Once the diagnosis is made, additional tests to rule-out concurrent ureteral injuries must be performed. If the diagnosis of a vesicouterine fistula is made within three to six months of the surgery, conservative treatment with a indwelling urethral catheter and endocrine suppression of menstrual flow has been successful in > 50% of patients. Once the tract has matured and epithelized as in this case, treatment is based on the future fertility desires of the patient. If the individual does not desire to have further children, the most definitive treatment is by transabdominal hysterectomy and repair of the bladder. If additional child bearing is requested, either transvaginal, or transabdominal approaches may be used dependent upon the location of fistula. Juxtaposition of adjacent tissue such as omentum or a labial fat pad (Martius flap) greatly reduces the likelihood of recurrence. These dissections are frequently complicated and placement of bilateral ureteral stents prior to the surgery to help identify the ureters is recommended.
Condyloma lata are associated with:
- cervical carcinom
- gonococcal urethritis
- herpes simplex virus
- secondary syphilis
- AIDS-related complex.
4
Condyloma lata are a cutaneous manifestation of secondary syphilis. They appear as flesh colored or hypopigmented, macerated papules or plaques. They most commonly involve genital and anal areas. The lesions are typically smooth and moist. Condyloma lata resemble condyloma acuminata but are distinguished by their smooth, flat and moist appearance. Condyloma lata have not been associated specifically with cervical carcinoma, gonococcal urethritis, herpes simplex, or HIV.
A seven-year-old boy with a seizure disorder is managed with a ketogenic diet and topiramate, has one episode of painless gross hematuria. Renal ultrasound demonstrates 3 mm stones in the lower pole of both kidneys without hydronephrosis. The next step is:
- consult neurologist for alternative seizure treatment
- urinary alkalinization
- oral penicillamine
- SWL
- ureteroscopic laser lithotripsy.
1
Both ketogenic diet and topiramate (Topamax) can cause calcium phosphate stones. This child with small non-obstructing kidney stones, discovered after a single episode of painless gross hematuria, does not require surgical intervention at this time. Seeking alternative seizure pharmacotherapy by consulting a neurologist is the best next step. The stone is likely calcium-based, and thus medical therapy aimed at uric acid (raise the pH) or cystine (oral penicillamine) stones are not appropriate.
While performing a videourodynamic study in a patient with neurogenic bladder, the patient develops a severe headache. The neurological condition most likely to be associated with this event is:
- hemorrhagic stroke in globus pallidus
- conus medullaris injury
- spinal cord infarct at T4
- astrocytoma displacing the reticulospinal tract at T8
- multiple sclerosis.
3
Autonomic dysreflexia is a medical emergency caused by over stimulation of the sympathetic nervous system in individuals with spinal cord injuries at or above the 5th thoracic (T5) spinal cord levels, although patients with injuries between T6-10 maybe susceptible. Autonomic dysreflexia is classically stimulated by: An overfilled bladder, colonic distension (constipation), decubitus ulcer or silent orthopedic fracture. Patients exhibiting autonomic dysreflexia are symptomatic with complaints of a headache, flushing and diaphoresis (above the level of the spinal cord lesion), HTN and bradycardia. Bradycardia occurs due to a reflex stimulated from stretch on the atrial ventricular node by the elevation in blood pressure. When seen in the office setting, the first step should be to empty the bladder and remove all noxious stimuli, i.e., cystoscope, urodynamic catheter, from the bladder. If the elevation in blood pressure does not respond, the patient should be treated with ½ to 1 inch of nitropaste to the chest wall. If rebound hypotension occurs the nitropaste maybe rapidly wiped off of the skin. Other options of pharmacologic therapy for autonomic dysreflexia in the office setting include oral or sublingual nifedipine. However, rebound hypotension can be problematic and difficult to deal with.
A 55-year-old diabetic woman has new onset pneumaturia. The next step is:
- pelvic CT scan
- cystoscopy
- urine culture
- cystogram
- barium enema.
3
Pneumaturia, the passage of gas in the urine, may be due to a fistula between the intestine and bladder or due to gas-forming UTI. Common causes of fistula are diverticulitis, carcinoma of the sigmoid colon, and regional enteritis (Crohn disease). Patients with diabetes mellitus may have gas-forming infections, with carbon dioxide formation from the fermentation of high concentrations of sugar in the urine. In the latter situation, the microorganism most commonly responsible for cystitis is E. coli. Approximately 60% of cases of emphysematous cystitis occur in diabetics. In the current case, a UA and urine culture should be performed first. Additional tests can be performed selectively based on the results of UA and urine culture. Culture results showing multiple organisms is suggestive of a colovesical fistula.
In 46 XX female patients with CAH, the clitoral nerves at the mid-portion of the enlarged phallic shaft are found:
- ventrally
- dorsally
- laterally
- between the urethra and vagina
- between the shafts of the corpora cavernosa.
2
The clitoral neural anatomy in the masculinized female patients with CAH is similar to that of the normal male or female phallus. At the mid-portion of the enlarged clitoral shaft, the nerves are found dorsally. This is the area which must be preserved for possible future genital sensation after the feminizing genitoplasty.
A 57-year-old woman reports a vaginal bulge ten years after hysterectomy. On examination, she is found to have anterior prolapse, with the most distal point noted at her hymenal ring. Her vault and posterior wall show no prolapse. The POP-Q points consistent with her exam are:
- Aa -1, C 0, Ap -3, stage 1
- Aa -1, C 0, Ap -1, stage 1
- Aa 0, C -7, Ap -3, stage 2
- Aa 0, C -7, Ap -1, stage 2
- Aa +1, C +2, Ap -3, stage 3.
3
The POP-Q (pelvic organ prolapse quantification) is a classification system used to quantify the degree of pelvic organ prolapse (POP). Nine points are measured in relation to the hymenal ring, which is designated as “0” (zero). Any points located above the hymenal ring are given a negative value, corresponding to the number of centimeters (cm) the point is above the hymen, whereas points distal to the hymen are given positive values. Aa and Ap correspond to the point three cm up on the anterior and posterior walls, respectively, and will be -3 if there is no POP. Ba and Bp correspond to the distal-most aspect of the anterior and posterior walls, respectively. The well-supported vault (C) should be at about -7 to -9. This patient has a cystocele and no posterior or apical prolapse. The distal-most portion of her anterior vagina is at 0, the level of the hymenal ring. Ap, which corresponds to approximately the level of the bladder neck, is -3. The vault is supported at -7. This is stage 2, which is defined as the most distal point of the POP being between +1 and -1, or within 1 cm of the hymen. Other points of measurements in POP-Q include the genital hiatus (GH), perineal body (PB), and total vaginal length (TVH).
A 26-year-old man has progressive left flank pain 17 years after an open pyeloplasty. Diuretic renography reveals 28%25 function from his left kidney with delayed renal pelvic drainage (T1/2 = 40 minutes). Retrograde ureterogram shows a 1 cm narrowing at the UPJ. The best treatment is:
- balloon dilation
- endopyelotomy
- nephrectomy
- pyeloplasty
- ureterocalycostomy.
2
Pyeloplasty may result in early or delayed failure. Failure is most likely secondary to an anastomotic stricture. Transmural endopyelotomy whether performed in a retrograde or antegrade approach is the treatment of choice. Ureterocalycostomy may be considered, but only after less invasive treatments. It should be reserved for patients with intrarenal pelvis, dilated lower calyces or a lengthy proximal ureteral stricture. Nephrectomy should be reserved for kidneys with minimal renal function. Balloon dilation is suboptimal therapy. Pyeloplasty, whether open or laparoscopic should be reserved for endoscopic failures.
A six-year-old boy has the sudden onset of gross hematuria, urgency, and frequency. Urinalysis shows 5-10 WBC/hpf and gross blood. Urine culture is negative. Ultrasound shows diffuse bladder wall thickening but no hydronephrosis or renal mass. The next step is:
- observation
- antibiotics
- VCUG
- non contrast CT scan
- cystoscopy.
1
This boy has typical signs and symptoms of viral cystitis. Adenovirus is the most common virus although viral cultures are infrequently done in this setting. Supportive therapy is the mainstay of management. An ultrasound should be done to rule-out other serious causes of hematuria. Bladder wall thickening is to be expected in the acute phases of a viral infection. Symptoms usually resolve within two to four weeks. Antimuscarinics can be used when the urgency and frequency is more severe. Ribavirin can be considered in highly symptomatic patients, especially in those that are immunosuppressed. There is no indication for antibiotics. If his symptoms do not resolve after a few weeks, then one can get a VCUG or perform cystoscopy to rule out PUV or other pathology. However, doing this in the acute phase is premature since the clinical suspicion for valves is low. If he had valves, one would have expected symptoms prior to this time. The clinical suspicion for a stone is also low given the ultrasound findings. Thus, getting a CT scan is not indicated especially in light of the unnecessary exposure to radiation which is a significant concern in children.
A 45-year-old obese man with untreated sleep apnea develops nocturnal enuresis. He has no daytime incontinence. Physical examination is unremarkable except for mild lower extremity edema. Urinalysis is negative, and his PVR is 30 ml. The most likely etiology of the enuresis is:
- decreased secretion of ADH
- increased secretion of atrial natriuretic peptide
- detrusor overactivity
- mobilization of lower extremity edema
- hypercarbia induced drowsiness.
2
Sleep apnea is a recognized cause of nocturia and secondary, or adult-onset, nocturnal enuresis. It causes nocturnal diuresis by a cascade of events which are precipitated by hypoxia which occurs during the intermittent occlusion that occurs with obstructive sleep apnea. The hypoxia-induced increase in right atrial transmural pressure leads to elevated atrial natriuretic peptide, resulting in increased nocturnal urinary output. Atrial natriuretic peptide secretion is induced by elevated intrathoracic pressures due to diaphragmatic contraction against a closed upper airway.
A 54-year-old man develops new onset of renal transplant hydronephrosis secondary to a 2 cm proximal ureteral stricture. Ultrasound reveals normal bilateral atrophic kidneys to be in situ. The next step is:
- double-J stent placement
- chronic nephrostomy drainage
- antegrade ureteral balloon dilation
- pyeloureterostomy to native ureter
- pyelovesicostomy.
4
Ureteral obstruction is difficult to manage in transplant kidneys. Long-term nephrostomy tube drainage increases infectious risks especially in immunocompromised patients and requires frequent tube changes. Double-J stents are difficult to place and replace in a retrograde fashion since the common ureteral reimplantation site for a transplant ureter is on the dome of the bladder. Antegrade balloon dilation of all ureteral strictures has poor long-term success. Open exploration is difficult due to the marked fibrous reactive tissue surrounding transplant kidneys. A pyelovesicostomy will freely reflux and may increase the risk of recurrent infections. Drainage through a native ureter anastomosed to the proximal renal pelvis (transplant kidney) is the best option for long-term success.
A 30-year-old man on CIC develops urinary incontinence three years after a spinal cord injury. Urodynamic testing demonstrates detrusor areflexia, and a detrusor LPP of 60 cm H2O at 200 ml. The next step is:
- tamsulosin
- ephedrine
- bethanechol
- oxybutynin
- dantrolene.
4
Detrusor compliance may deteriorate in patients with spinal cord injury and detrusor areflexia. The development of incontinence suggests this occurrence. A detrusor LPP greater than 15 cm H2O indicates that compliance is impaired. In the absence of intervention, renal deterioration may occur. The best treatment is an antimuscarinic agent, such as oxybutynin. Ephedrine would be contraindicated as it may increase sphincter tone and increase detrusor LPP. An alpha-1-blocker may lower the detrusor LPP, but increase the incontinence. Bethanechol would also be contraindicated since it may increase detrusor pressure. Dantrolene is used to treat detrusor external sphincter dyssynergia via relaxation of skeletal muscle.
A 37-year-old woman with a suspected urinary fistula undergoes an in-office double dye test. There is orange staining of the upper gauze pad. The middle gauze pad is dry, and the lower gauze pad is slightly stained blue. The most likely diagnosis is:
- ureterovaginal fistula
- vesicovaginal fistula
- ureterovaginal and vesicovaginal fistula
- ureterovaginal fistula and urethral leakage
- vesicovaginal fistula and urethral leakage.
4
The in-office dye test begins with prescribing oral phenazopyridine several days prior to office visit. As expected, this process will turn the urine orange. At time of office visit, the bladder is filled with dilute methylene blue via urethral catheter infusion. Thus, bladder fluid will have blue coloration, and ureteral urine is expected to have orange discoloration. Three gauze pads are placed in the vagina, the upper pad is near the cuff, and the middle pad is within the vagina, usually above the bladder neck. The lower pad is usually below the bladder neck and urethra. In this pattern of staining, orange urine in the upper pad is concerning for the presence of a ureteral source of drainage into the vagina, most commonly a ureterovaginal fistula. The appearance of blue staining on the lower pad is most consistent with urethral leakage. Thus this patient has results suggestive of a ureterovaginal fistula and urethral leakage. The presence of blue on the upper or middle pad without leakage on the lower pad would suggest a vesicovaginal fistula.
The need for operative revision of stomal stenosis in a continent, catheterizeable channel is reduced by:
- increasing size of catheter
- increasing frequency of catheterization
- steroid injection of stoma
- use of a pre-lubricated catheter
- leaving a catheter through superficial portion of stoma nightly.
5
The usual first line approach for the problem of cutaneous stenosis of a Monti or Mitrofanoff channel is to leave a catheter through the stoma for some period of time. The concern with leaving a full-time indwelling catheter to stent the stoma for several days is that it may plug with mucous and introduce bacteria along its surface into the bladder. Mickelson, et. al., reported use of the L-stent, a catheter with a knot tied just 1-2 inches from the tip, inserting it up to the knot at night with taping to hold it in place. This serves to stent only the cutaneous stoma and not enter the bladder itself. Their success with a modest period of nighttime stenting was excellent. None of the other approaches listed have shown particular impact on this problem.
A 22-year-old man sustains a severe burn of his genitalia. There is marked bullous edema and eschar formation of the entire penis and much of the scrotum. He has had a catheter in his urethra for three days to monitor urine output. The next step is:
- radical eschar debridement
- split thickness skin grafts
- hyperbaric oxygen therapy
- remove urethral catheter and insert suprapubic tube
- observe for wound granulation.
4
Multiple debridements of necrotic skin followed by skin graft coverage may eventually be needed with burn injuries to the genitalia. Early suprapubic urinary diversion simplifies wound care and prevents complications related to prolonged urethral catheterization. If a urethral catheter is used in a genitalia burn, it should be removed after 72 hours to prevent urethral slough and fistula formation. Hyperbaric oxygen therapy has been used to promote overall wound healing however there is no evidence that it prevents urethral complications. Split or full thickness skin grafting is used once granulation tissue is present and all non-viable tissue has been removed.
